1. Arthroscopic Treatment of Multi-Directional Instability of the Shoulder
Raymond Y. Whitehead, M.D.

2. Shoulder Stability Dependent upon a variety of anatomic factors
Static restraints of capsulolabral complex
Negative intra-articular pressure
Dynamic compression from intact cuff

3. Shoulder Instability
Laxity - objectively describes the extent to which the humeral can be translated on the glenoid
Instability - is an abnormal increase in glenohumeral translation that causes symptoms (subluxation or dislocation)

4. Classsification of Instability - “TUBS”
Traumatic
Unidirectional
Bankart lesion
Surgery to achieve stability

5. Classsification of Instability - “AMBRII”
Atraumatic
Multidirectional
Bilateral excessive laxity
Rehabilitation usually therapeutic
Inferior capsular shift if surgery required
Rotator Interval closure

6. Continuum of Shoulder Instability
Now viewed as a spectrum
Atraumatic
Multidirectional
Microinstability from repetitive microtrauma
Bidirectional
Traumatic unidirectional

7. Pathophysiology
The anatomic lesion found in MDI is a large, patulous inferior capsular pouch that extends both anteriorly and posteriorly in varying degrees, creating a global increase in capsular volume.
Redundant inferior glenohumeral ligament complex with a resultant increase in capsular volume.

8. Pathophysiology
The inferior capsule resists inferior translation increasingly with progressive arm abduction to 90 degrees
Rotator interval widening with attenuated tissue, appearing as a broad cleft.
The rotator interval resists inferior translation with the arm at the side

9. Pathophysiology Effect of rotator cuff Dynamic stabilization
Effect of concavity compression
Scapular stabilizers
Synovial fluid adhesion-cohesion stabilization forces
Negative intra-articular pressure

10. Pathophysiology Self-perpetuating viscous cycle
Asymptomatic patient with laxity
Pain or fatigue secondary to repetitive use or traumatic event
Painful protected shoulder results in muscle weakness and diminished neuromuscular coordination
Exxacerbation of instability
More pain and subsequent weakness secondary to disuse

11. Etiology Congenital bilateral generalized ligamentous laxity Acquired
Repetitive stress
Overhead athletes
Manual laborers
Traumatic
Congenital laxity exacerbated by traumatic subluxation/dislocation

12. Clinical Features of MDI
Symptomatic with activity
Objective evidence of glenohumeral subluxation or dislocation

13. History Most common complaint is pain Pain:
ADL’s
Overhead activity
Repetitive motion
Sensation of shoulder looseness
Often no frank history of dislocation

14. History Voluntary vs. Involuntary Neurologic symptoms
transient numbness, tingling, and weakness
provocative positions and activities

15. Physical Exam
Inspection
Atrophy
Deltoid contour
Supraspinatus contour

16. Physical Exam Generalized ligamentous laxity ROM - passive and active
elbow hyperextension
MCP joint hyperextension
genu recurvatum
patellar subluxation
thumb-to-forearm
ROM - passive and active

17. Physical Exam Motor strength Neurologic testing Palpation
AC jt
Acromion
Provocative testing
impingement
O’Brien, Speed, etc.

18. Physical Exam - Instability Testing
Sulcus test
adducted arm assesses the rotator interval
90 degrees abduction assesses the inferior capsule
Load-and-shift
vary both abduction and external rotation
Anterior stress (lachman of shoulder)
Posterior stress
Apprehension

19. Radiographic Exam True AP Axillary Supraspinatus Outlet MRI
Little to no role in pure MDI
Useful to assess concomitant labral, intra-articular , and rotator cuff pathology

20. Differential Diagnsosis
MDI
Traumatic instability
Combined
Impingement
Cervical radiculopathy
Thoracic outlet
Other labral lesion

21. Nonoperative Treatment
Patient education
Physical therapy
Rotator cuff strengthening
Scapular stabilization
Neuromuscular coordination
NSAIDS & analgesics prn
Burkhead and Rockwood
88% successful treatment of MDI with rehab

22. Surgical Candidates Compliant patients Failed rehab X 6 months
Continued symptoms

23. NO Surgery Voluntary dislocators Emotionally unstable
Behaviorally immature teenagers

24. Surgical Options Open inferior capsular shift Glenoid osteotomy
Thermal capsular shrinkage
Arthroscopy

25. Caution
A patient with generalized laxity who experiences an inciting traumatic event may experience clinical failure of operative treatment if capsular laxity not addressed at the time of Bankart / surgical reconstruction.
Speer et al. JBJS, 76A, 1994
Capsular injury associated with dislocation and creation of Bankart lesion

26. Open Capsular Shift Altchek, JBJS, 1991
95% excellent with glenoid based shift

27. Open Capsular Shift Neer & Foster, JBJS, 1980
97% excellent with humeral based shift

28. Open Capsular Shift
Jobe -ACLR

29. Open Capsular Shift Bigliani, AJSM, 1994
recurrence rate of 1.5%
The inferior capsular shift, either glenoid or humeral based, is the standard procedure for surgical management of MDI.

30. Advantages of Arthroscopy
Improved cosmesis
Complete glenohumeral inspection
Address all labral pathology
Treat intra-articular lesions
Maximal preservation of motion
Diminshed post-op pain
Less blood loss

31. Arthroscopic Options Staple Capsulloraphy
Transglenoid Suture capsulloraphy
Thermal capsulloraphy
RF vs. Laser
Rotator interval plication
Arthroscopic Capsular plication

32. Caspari multiple suture transglenoid capsular shift
McIntyre, et al, “The Arthroscopic Treatment of MDI: 2-year Results of a Multiple Suture Technique,” Arthroscopy, 13(4), 1997,
Caspari multiple suture transglenoid capsular shift
19 patients with symptomatic MDI
14 injured in athletics
4 frank dislocations
Surgical findings
7 with anterior & posterior bankart lesions
2 with anterior bankart lesion alone
2 with labral fraying
9 with excessive capsular laxity

33. McIntyre, et al, Arthroscopy, 13(4), 1997, 418-425.
Arthroscopic Technique
Capsular incision adjacent to labrum if no bankart
Anterior sutures placed transglenoid

34. McIntyre, et al, Arthroscopy, 13(4), 1997, 418-425.
Posterior capsular release from glenoid
5 mm tag inferiorly at inferior glenoid b/w incisions
Posterior sutures placed transclavicular or through spine of scapula

35. McIntyre, et al, Arthroscopy, 13(4), 1997, 418-425.
1 repeat anterior subluxation
Treated with repeat arthroscopic procedure
13 excellent, 5 good, & 1 fair result
All athletes returned to previous level of athletic participation
Minimal loss of ROM
Conclusion: The described technique proved safe and effective in treating MDI and enabling athletes to return to their previous level of function.

36. Thermal Capsulorraphy
Capsular shrinkage secondary to heat delivered by either a RF probe or laser
Heat disrupts crosslinks in Type I collagen causing contraction of the triple helix
Greater response in tissue with higher collagen densities (IGHL, MGHL)

37. Thermal Capsulorraphy
RF energy provides shortened scaffold for fibroblasts to lay down new collagen
Maturation process may take 4-6 weeks
Therefore, immobilization required to prevent activities which may stretch scaffold
In vivo results of elongated tissue after shrinkage without immobilization

38. Thermal Capsulorraphy
Little clinical data
Long term effects of thermal modification of tissue are unknown
Recent literature somewhat pessimistic and detrimental
More info required before more widespread use recommended

39. 33 patients with MDI min. 6 mo. Follow-up 1-bankart & 3-SLAP
JP Bradley, “ Thermal Capsulorraphy for MDI,” Instr. Course Lect., 2001.
33 patients with MDI min. 6 mo. Follow-up
1-bankart & 3-SLAP
10 unsatisfactory (29%)
Because of high failure rate, increased immobilization from 2 to 6 weeks
Anecdotally improved results for the next 60 patients enrolled in the study

40. 30 patients with unipolar RF shrinkage with combined RI plication
Savoie & Field, “Thermal vs. Suture Treatment of Symptomatic Capsular Laxity,” Clin Sports Med, 2000.
30 patients with unipolar RF shrinkage with combined RI plication
2 dislocations
rehab begin after 3 weeks in sling
28 of 30 rated satisfactory (93%)
2 failures (7%)
one with early return to sport
other did well for 18 months then with recurrent subluxations

41. 26 patients with arthroscopic transglenoid capsular shift
Savoie & Field, “Thermal vs. Suture Treatment of Symptomatic Capsular Laxity,” Clin Sports Med, 2000.
26 patients with arthroscopic transglenoid capsular shift
15 dislocations
3 patients with recurrent instability
1 - high school pitcher with loss of velocity
1 - college basketball

42. 32 patients with YAG-laser capsular shift
Savoie & Field, “Thermal vs. Suture Treatment of Symptomatic Capsular Laxity,” Clin Sports Med, 2000.
32 patients with YAG-laser capsular shift
2 patients unable to return to collegiate level baseball
1 - recurrent instability
1 - RTC tear

43. Savoie & Field, “Thermal vs
Savoie & Field, “Thermal vs. Suture Treatment of Symptomatic Capsular Laxity,” Clin Sports Med, 2000.
Conclusion:
Clinical results of thermal capsulorraphy are comparable to arthroscopic shift and laser shift
Results suggest thermal capsulorraphy is an effective treatment alternative for patients with MDI

44. Thermal Capsulorraphy Unknowns
Long term effect on capsular tissues
Effect of temperature on proprioception and nerve endings
Time for capsular collagen reorganization
In patients with congenital laxity does collagen become more lax over time.
No long term outcomes

45. failed 6 months rehab, activity modification, and NSAIDS
Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001,
47 patients with true MDI
excluded work comp & instability in 2 directions
failed 6 months rehab, activity modification, and NSAIDS
20 recurrent dislocators
27 recurrent subluxators

46. Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001,
Operative Technique
Goal: repair ligament or labral detachments anatomically, then recreate adequate capsular tension
Labrum was not shifted but repaired anatomically
Ligament and capsular advancement onto labrum or glenoid rim as dictated by individual anatomy (capsular plication)
Typically 5 to 15 mm of lateral and superior ligament advancement performed
Anterior, inferior, and posterior capsule addressed
Rotator interval plication

47. Post-op management 15 degree abduction sling x 6 weeks
Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001,
Post-op management
15 degree abduction sling x 6 weeks
begin AROM at 2 weeks
FF limited to 90
ER limited to 40
unrestricted AROM and strengthening at 6 weeks

48. Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001,
Operative Findings
Essential finding was large capsular volume and excessive humeral head translation anteriorly, inferiorly, and posteriorly
Labral repair alone not sufficient to restore stability alone
All patients required capsular tightening

49. Post-operative Scores and Ratings
Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001,
Post-operative Scores and Ratings
ASES, Constant, Rowe, & UCLA
All significantly improved
final Rowe score of 93.7
45 of 47 rated good to excellent satisfaction with UCLA

50. 4 of 28 not return to sports participation 1 - persistent instability
Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001,
4 of 28 not return to sports participation
1 - persistent instability
1 - pain with throwing
2 - loss of strength
One failure at 18 months with recurrent subluxation
revision surgery showed unhealed superior portion of bankart

51. Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001,
Conclusion:
Patients with MDI have multiple lesions within the shoulder and the surgeon must individualize the operative treatment.
Repair of rotator interval was an essential element to the operative treatment
Arthroscopic anatomic repair of all labral attachments and suture capsulorraphy to restore capsular tension produced successful results.

52. Traumatic anterior inferior instability 34 patients
Tauro, “Arthroscopic Inferior Capsular Split and Advancement for Anterior and Inferior Shoulder Instability: Technique and Results at 2-5 year Follow-up,” Arthroscopy, 16(5), 2000,
Traumatic anterior inferior instability
34 patients
22 – anterior inferior dislocations
10 – chronic recurrent anterior inferior subluxations
2 – MDI
5 – acute first time dislocators
Surgical findings
29 – Bankart lesions
5 – labral abrasions with markedly lax ant/inf capsules

53. Tauro, Arthroscopy, 16(5), 2000,
Inferior Capsular Split

54. Tauro, Arthroscopy, 16(5), 2000, 451-456. Post-op
Shoulder immobilizer x 4 weeks
Immediate ER to 0 degrees
Immediate Abd to 45 degrees
Immobilizer 4wks
Begin ER to 30 and full Abd along with light resisted IR & ER
8 wks – progress to full ROM and strengthening

55. Tauro, Arthroscopy, 16(5), 2000, 451-456. Results
No recurrences in acute dislocators
1 chronic subluxator with recurrent subluxations
3 chronic dislocators with recurrent dislocations
Caused by trauma
2 of 5 failures in transglenoid recurred
2 of 29 in failures suture anchor group
Minimal loss of ROM
Good rate of return to prev activity

56. Tauro, Arthroscopy, 16(5), 2000, 451-456. Conclusion
Do not detach capsule if no bankart present (capsular plication only)
Addition of inferior capsular split and advancement to bankart procedure addresses plastic capsular elongation as a result of dislocation and therefore may improve results of arthroscopic treatment of anterior inferior instability.

57. No documented dislocations (one with hx of reduction in ER)
Wolf & Eakin, “Arthroscopic Capsular Plication for Posterior Shoulder Instability,” Arthroscopy, 14(2), 1998,
14 patients
Pain with overhead activity and with provocative motions (flex, IR, Add)
No documented dislocations (one with hx of reduction in ER)
Positive “jerk” test
post stress with flex, IR, Add
6 mo. Pre-op rehab

58. Wolf & Eakin, Arthroscopy, 14(2), 1998, 153-163.
EUA – unilateral posterior instability
Arthroscopic Technique
Posterior portal 1-2 cm more inferior and lateral than usual
Capsular abrasion
Plication with Linvatec crescent suture hook & No. 1 PDS
Arthroscopic findings
Posterior capsular laxity in all patients
8 with labrals lesions (reverse bankart)

59. Wolf & Eakin, Arthroscopy, 14(2), 1998, 153-163.
11 returned to preinjury level
4 collegiate & high school athletes
11 full return of strength
1 recurrent instability 5 mo. Post op
1 work comp case
Conclusion – Capsular plication is a promising technique for addressing capsular laxity in patients with recurrent posterior shoulder instability

60. Nebelung et al, “A New Technique of Arthroscopic Capsular Shift in Anterior Shoulder Instability,” Arthroscopy, 17(4), 2001,
Designed to address redundant anterior & inferior capsuloligamentous tissues as a result of repeated ant/inf. Dislocations
Vertical mattress suture through capsular tissue to imbricate capsule onto labrum
Secured with an anchor

61. Treatment of MDI with Suture Plication J.C. Esch Metcalf Course 2001
Surgical Goals:
Eliminate capsular redundancy
Tighten loose structures
“Widen” glenoid
Reduce joint volume
Balance loose ligaments

62. Treatment of MDI with Suture Plication
Tighten:
posterior band of IGHL
anterior band of IGHL
advance MGHL superiorly to close the rotator interval
Capsular abrasion prior to plication

63. Treatment of MDI with Suture Plication
Snyder, AANA 1999
23 patients with no bankarts
87% satisfied; 18 exc/good Rowe scores
Wolf, AANA 1999
20 MDI; 13 trauma & 9 atraumatic
75% good/exc
5 patient with recurrent instability

64. Contraindications to Arthroscopy
Nelson & Arciero, AJSM, 28(4) 2000
patients with excessive capsular laxity, bilateral atraumatic shoulder instability, and signs of excessive ligamentous laxity are not ideal candidates for arthroscopic stabilization
patients with no bankart lesion and a large, patulous inferior pouch are poor candidates for arthroscopic stabilization.
Patients participating in collision sports.

65. Contraindications to Arthroscopy
Romeo, AANA, Nov., 2000
Contact athletes
History of multiple recurrences
Anterior instability with NO bankart lesion
“Poor quality” tissue
Pathologic ligamentous laxity

66. Nelson & Arciero, AJSM, 28(4) 2000
Arthroscopic management of MDI is still in its developmental stage. There are few studies available for review, and the published reports have small numbers and short follow-up.
A further problem is the diverse presentation and pathoanatomy observed in patients with MDI

67. What is the Problem?
Studies on MDI include patients with a variety of pathologic lesions
“Spectrum of instability”
Address capsular laxity with traumatic lesions
Difficult to interpret results
Different expectations for different patients
Pain in overhead worker
Elite overhead athlete?

68. What To Do?
Overhead athlete (thrower, tennis, swimming, gymnastics) with subtle instability and pain. Moderate anterior and inferior laxity and subluxation with no hx of dislocation. Failure to respond to rehab. No labral pathology. +/- mild internal cuff abrasion

69. What To Do?

70. What To Do? Most difficult Does thermal have a role?
Capsular Plication
Rotator Interval Plication

71. Arthroscopic Managment of MDI Summary
Address all labral palthology
Address associated capsular laxity
Capsular plication
Capsular shift
+/- Thermal
Rotator interval plication
Critical review and continued evaluation of results

72. THE END